Provider Demographics
NPI:1891489639
Name:BENNETT, MONIQUE (OD)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9256 HALLMARK PL
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-8597
Mailing Address - Country:US
Mailing Address - Phone:510-672-0945
Mailing Address - Fax:
Practice Address - Street 1:4051 LONE TREE WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-6204
Practice Address - Country:US
Practice Address - Phone:925-757-7676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35453152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty